Getting tested for H1N1 flu in Singapore

A colleague of mine returned to Singapore on Wednesday, May 27 from Boston, USA, where he'd spent the week between May 17 and May 24. He came back with a cold, a bad one.

He was sure it was a cold, not the flu: his temperature had not gone over 36 degrees C (98 F), he had no fever, no headache, no chills. He had cleared the thermal screening at Singapore's Changi Airport. But he had a meeting with a client scheduled on Friday, May 29, so he informed the client on Thursday, May 28 of his condition. The client asked him to (quoting the client's e-mail) "get clearance from a doctor that it is just a common cold, and not something serious" before coming to their office. He called his doctor on Friday morning, 29 May.

This is his first-hand, contemporaneous account of his experience as a suspected carrier of H1N1.

9.40 Call my doctor. All patients who have been to Mexico, USA or Canada and who have any of the flu symptoms, have to go to Tan Tock Seng Hospital (TTSH) by ambulance. [TTSH is Ground Zero for infectious disease in Singapore. It was the focal point for response to SARS, H5N1 "bird flu" and now H1N1 "swine flu". Five TTSH health care workers died of SARS in 2003 as a result of caring for patients.

9.45 Call the 993 ambulance. [A special ambulance for patients suspected of carrying infectious diseases. The attendants wear full protective suits, including respirators.]

Infection prevention poster in Singapore. Source: Health Promotion Board

10.30 Ambulance arrives and off we go. Get in the back and sit on a bench seat with little padding. Two routes to take: one with three right-hand turns and no humps; the other, five left-hand turns and several humps. [Note: my colleague lives very close to TTSH, which explains his intimate knowledge of the number of turns required to get there.] We take the one with the humps; the driver must have been trained by United Parcel Service (UPS). Very uncomfortable ride, no place to hold on. Find the seat belts and try to put them on, but they are too big and can't be adjusted.

10.40 Arrive at TTSH. Drive into ambulance bay past a group of five people--1 doctor and 4 traffic directors. No other vehicles around.

10.45 Get out of ambulance; no one wants to sign for me. After three attempts, someone does sign the driver's form and I can go in. Pass over my IC [national identity card] and take a seat on a white plastic chair in a concrete structure that is an extension of the hospital.

From a posted sign, this is a decontamination unit that has been converted into an H1N1 screening unit. No doors on the sides, and no air-conditioning, as it's open air. There are a few ceiling and several standing fans, but it's still hot. About 30 white plastic garden chairs are arranged about 2.5 meters apart in four rows. There is a large portable toilet that can accommodate disabled patients at one end, and 6 hospital beds. There is a small TV in the centre, but only a few can see or hear it. I manage to get a seat at the end where the nurses congregate; it's also the farthest from the porta-loo. There are 10 people sitting on the chairs and all the hospital beds are occupied by patients who appear to be asleep.

11.00 A bottle of water arrives.

11.10 A nurse with a trolley and a laptop pull up at my chair to get my basic details, including what my symptoms were and where I had visited.

11.30 Move to seat next to a doctor, nurse takes my temperature with ear thermometer, my blood pressure and heart rate. This seat is back-to-back with patients' seats where the doctor is doing the tests. So as each patient arrives, I can't help but hear their symptoms, where they work, etc.

A mother, 6-month-old baby and maid arrive. No special masks available for baby, the standard size is too big, so they don't use a mask. The other seats have now filled up.

Two lines for the test swabs, one with a nurse who does one round of throat and nose swabs, the other with the doctor who does two rounds of swabs and a blood test.

12.00 Lunch time. The choices are porridge, or a bun and crackers.

12.30 My turn and I get the doctor. He goes through all my personal and travel details, as well as drug allergies and current medication. Then it's time for the swabs. He seems to delight in seeing how far down my throat the swab can go. I ask him why he needs a second round, to which he replies: "Just in case there is a problem with the first one." Then, (oh joy of joys!) it's time for the blood test. Not too bad. Why is there a need for a blood test if it's not required for H1N1 screening? Oh, it's to check in case I have picked up anything else on my travels. [See related story No blood test for influenza]

"So, doctor, what happens now?" I ask.

"Well, sir, you have to wait four to six hours for the test results."

"OK, I'll go home and come back later."

"No, sir, you have to stay here until we have the results."

Now I know why those people are sleeping on the hospital beds.

So I am resigned to spending six hours sitting on the white plastic chair. It's quite uncomfortable, so I decide to go on a walkabout every 15 minutes.

The ambulance driveway is being converted into an extension of the facilities I am in. So I get to see how the power, wash basins, fans, coolers, network and TV are set up. The National Parks Department bring planters and four ladies to supervise. An hour later, more planters arrive. They take out old ones, replace them with the new ones. The only difference I can see is that they are now alternate colors black and silver, and the four ladies seem happy. Someone takes digital photos of the new set-up. Looks like this is the area being set up for local cases as opposed to imported cases.

Nurses are beavering around, moving folders from place to place. When they open a folder, they spend more time trying to stop the paper from flying away [because of the fans]. The objective of the exercise seems to be to complete a giant spreadsheet.

3.00 Time for a portable chest x-ray.

3.30 Another bottle of water.

4.00 My name is called, but only to check my mobile phone number.

5.30 Blood pressure, temperature and heart rate are taken for the last time. Seems to be on a 2-hour cycle.

6.30 I finally ask the nurse where the results are. She checks and informs me that the results have been in since 6.00 p.m. but the doctor is still processing them. Seems that all the results are now done as one big batch, so none of us get any results.

7.00 They start releasing the results.

7.15 I get mine. I am informed that I have a common cold, and get an MC [medical certificate] for 3 days and a prescription for a cough that I don't have. When I ask about the prescription, I am told that it will help my cold. I also get the bill for S$85 (US$56).

On the way out, I see that the reception staff now have new cases that have taken up residence on their chairs. They look to be in for a long night.

7.30 Go to a tented extension. Here, there are dozens of empty surgical beds and makeshift wards. I feel that my mask needs to be N95 in this area. Finally I find the payment area and get out as quickly as possible.

7.45 Call my wife and get home at 8pm. Total time 9.5 hours, which now seems quite good as I find that the average time for such process is 12 hours.

Overall, I think the process needs to be reworked. The longest period of time is to check the sample swabs. This is a simple process and can be done as soon as they have the printed name tags, i.e. 30 minutes after arriving, rather than almost 2 hours, in my case.

Patients should also be told the situation under which a blood test is required. From my perspective, it seemed quite arbitrary. If a blood test is done, the patient should be given some indication of the result.

BCP Confidential note: There is no blood test for influenza in current clinical use for humans. See No blood test for H1N1. An agar gel immunodiffusion (AGID) test is considered a basic screening procedure to detect the presence of influenza Type A antibodies in the blood of domestic animals in the United States.

Once the tests are back and the results assessed, they should be given out one-by-one rather than batching them up.

Finally, I really appreciate the work done by these doctors and nurses. They have to be full-suited the whole day, don't seem to get much rest and are probably not paid enough for the risks they have to take.

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Nathaniel Forbes

Nathaniel Forbes is the director of Forbes Calamity Prevention, a Singapore-based consulting firm providing business continuity, crisis management and emergency response advice and training to multinational companies, with a focus on companies with offices in Asia. The firm is 10 years old. FCP's current and past clients include Singapore Exchange Ltd, OCBC Bank, AXA Insurance, The Gillette Company, Siemens and ABN Amro Bank. A former President of the Singapore Computer Society’s Business Continuity Group, Nathaniel passed the DRII’s Certified Business Continuity Planner (CBCP) examination in 1997. He has lived, traveled or worked in Asia since 1973.